Qualifying Hospice Guidelines · Support and Care for Terminally Ill Patients and their Families...

Qualifying Hospice Guidelines

121 S. Arthur St. • Phone 509.456.0438 • Toll-Free 888.459.0438 • Fax 509.458.0359 [email protected] • www.hospiceofspokane.org

2014

ALSCancer

DementiaHeart Disease

HIVLiver Disease

Pulmonary DiseaseRenal DiseaseStroke/Coma

If you have any questions,please contact us for assessment.

121 South Arthur St. PO Box 2215 Spokane, WA 99210Phone 509.456.0438 Toll-Free 888.459.0438 Fax 509.458.0359

[email protected] • www.hospiceofspokane.orgSupport and Care for Terminally Ill Patients and their Families

Qualifying Hospice Guidelines

Hospice of Spokane has provided this book to help clinicians determine when a patient may be eligible for hospice services. Patients are eligible for hospice care once a physician certifies that an individual's life expectancy is six months or less if the illness runs its normal course. Patients also need to have a desire to focus their care on comfort and quality of life, rather than curing the disease. Information for these sheets was obtained from CMS.

These guidelines are designed as a tool to help determine prognosis as it relates to making a hospice referral. They are not intended to be used to formulate diagnosis and do not confirm/rule out hospice qualification.

If a patient meets the medical guidelines, they are eligible to receive hospice care. Some patients may not meet the medical guidelines, but often do still qualify for hospice care because of other co-morbidities or rapid functional decline. It is the physician's judgment when determining the normal course of an illness and a prognosis of six months or less. After the referral, the Hospice of Spokane Medical Director will review the referral, and if he or she concurs, the patient will be admitted.

Hospice of Spokane is committed to providing hospice care to anyone, of any age, with any illness regardless of their ability to pay. To refer a patient to Hospice of Spokane or for information, contact our admissions department at 509.456.0438 or email [email protected]. Contents of this book contain qualifying information on the following disease areas:

ALS Cancer

DementiaHeart Disease

HIV Liver Disease

Pulmonary DiseaseRenal DiseaseStroke/Coma



Qualifying Hospice Guidelines for ALS

Severe nutritional insuffi ciency is defi ned as: dysphagia with progressive weight loss of at least 5% (with or without election for gastrostomy tube insertion).

Critically impaired respiratory function as defi ned by:1. FVC < 40% (seated or supine) predicted and 2 or more of the following:

Patients are considered eligible for hospice care if they do not elect tracheostomy and invasive ventilation and display evidence of critically impaired respiratory function (with or without use of NIPPV) and/or severe nutritional insuffi ciency (with or without use of a gastrostomy tube).

• Dyspnea at rest• Orthopnea• Use of accessory respiratory musculature• Paradoxical abdominal motion• Respiratory rate > 20• Reduced speech/vocal volume• Weakened cough• Symptoms of sleep-disordered breathing• Frequent awakening• Daytime somnolence/excessive daytime sleepiness• Unexplained headaches• Unexplained confusion• Unexplained anxiety• Unexplained nausea

2. If unable to perform the FVC they should manifest 3 or more of the above symptoms/signs

Information obtained from CMS. This sheet is designed as a tool to help determine prognosis as it relates to making a hospice referral. This sheet is not intended to be used to formulate diagnosis and does not confirm/rule out hospice qualification. If the patient meets the factors you may wish to make a referral to Hospice of Spokane. You may do so by calling 509.456.0438 or filling out the online referral form at http://hospiceofspokane.org/admissions.html.



Qualifying Hospice Guidelines for Cancer

KPS _________ PPS _________

A. Disease with metastases at presentation

Cancer criteria must have Part A or B

Cancers with poor prognosis (small cell lung, brain and pancreatic) may be hospice-eligible without fulfi lling the other criteria.

1. Continued decline in spite of therapy; or

Or

B. Progression from an earlier stage to metastatic disease with either:

2. Patient declines further disease directed therapy

Non-disease specifi c guidelines to be used in conjunction with above criteria (both A and B should be met)

A. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) <70%

B. Must be dependent in 2 or more of the following ADLsFeeding _____ Ambulation _____ Continence _____Transfer _____ Bathing _____ Dressing _____

Co-Morbidity severity should be considered in determining prognosis for hospice eligibility:

COPD _____ CHF _____ Ischemic heart disease _____Diabetes mellitus _____ Neurologic dx _____ Renal failure _____ Liver disease _____ Neoplasia _____ AIDS _____

Dementia _____ Other _____ Refractory severe autoimmune disease _____



Moribund / imminent death 10 _____Very sick / active supportive tx 20 _____Severely disabled / req close monitoring 30 _____Disabled / req special care / assistance 40 _____Req much assistance / freq med care 50 _____Req occasional assist / self care most ADL 60 _____Self Care ADL’s / limited activity 70 _____Normal activity with effort / S&S of dx 80 _____Normal activity / minor S&S of dx 90 _____No evidence of dx 100 ____

Totally bed bound / unable to do any activity; intake: mouth care only; drowsy or coma 10 _____Totally bed bound / unable to do any activity; intake: minimal to sips; full or drowsy 20 _____Totally bed bound / unable to do any activity; intake: normal / reduced; full or drowsy 30 _____Mainly in bed / unable to do most activity mainly assist; intake: normal / reduced; full or drowsy 40 _____Mainly sit / lie / unable to do any work; considerable assistance req; intake: normal / reduced; full or confusion 50 _____Activity unable hobby / housework; req occasional assistance; intake: normal / reduced; full consciousness / confusion 60 _____Unable to do normal job / work; indep. care; intake: normal / reduced; full consciousness 70 _____Full / normal activity with effort; indep. care; intake: normal; full consciousness 80 _____Full / normal activity and work; indep. care; intake: normal; full consciousness 90 _____Full / normal activity and work; indep. care; intake: normal; full consciousness 100 ____


Karnofsky Status – Pick one value (status of 70% or less required)

Palliative Performance Score – (Poor functional status at or below 70%)

Karnofsky Status (<70%) _____

Palliative Performance Score (<70%) _____



Qualifying Hospice Guidelines for Dementia

_____ FAST Score stage 7

1. Patients with dementia should have all of the following to qualify for hospice care:

Note: This section is specifi c for Alzheimer’s and related disorders, and is not appropriate for other types of dementia.

_____ Unable to ambulate w/o assistance _____ Unable to dress w/o assistance _____ Unable to bathe w/o assistance _____ Urinary / fecal incontinence (intermittent or constant) _____ No consistently meaningful verbal communication. Stereotypical phrases only or <6 intelligible words

2. Patients with dementia should have had one of the following within the past 12 months:

_____ Aspiration pneumonia

_____ Pyelonephritis

_____ Septicemia

_____ Multiple decubitus ulcers Stage 3-4

_____ Recurrent fever after antibiotics _____ Inability to maintain sufficient calorie intake w/ 10% wt loss during previous 6 months or serum albumin <2.5 gm/dl

Reisberg FAST Score – (Stage 7 plus all of the required elements)

Requires assist dressing 6a _____Requires assist bathing 6b _____Requires assist toileting 6c _____Incontinent of urine 6d _____Fecal incontinence 6e _____Speaks <6 intelligible words 7a _____Speaks / repeats 1 intelligible word 7b _____Cannot ambulate without assistance 7c _____Cannot sit without assistance 7d _____Loss of ability to smile 7e _____Unable to hold head up independently 7f _____

_



Information obtained from CMS. This sheet is designed as a fact-finding tool to help determine prognosis as it relates to making a hospice referral. This sheet is not intended to be used to formulate diagnosis and does not confirm/rule out hospice qualification. If the patient meets the factors you may wish to make a referral to Hospice of Spokane. You may do so by calling 509.456.0438 or filling out the online referral form at http://hospiceofspokane.org/admissions.html.





FAST (if applicable) _____





Qualifying Hospice Guidelines for Heart Disease

1. _____ Patient has been optimally treated for heart disease. If not on vasodilator pt has a medical reason for refusing these drugs: (hypotension or renal disease)

Heart Disease:

NYHA Functional Class

_____ Patient not a candidate for surgical procedure OR

_____ Patient declines surgical procedure

2. _____ Patient should meet criteria for NYHA Class IV. Significant CHF may be documented by an ejection fraction of <20% but not required if not readily available

_____ Class IV Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Data from both 1 & 2 should be present to qualify for hospice care

_____ Class III Marked limitation of physical activity. Comfortable at rest, but less than (Moderate) ordinary activity causes fatigue, palpitation or dyspnea (shortness of breath).

_____ Class II Slight limitation of physical activity. Comfortable at rest, but ordinary (Mild) physical activity results in fatigue, palpitation or dyspnea.

_____ Class I No limitation of physical activity. Ordinary physical activity does not cause (Mild) undue fatigue, palpitation or dyspnea.

Supporting data (not required)

_____ Tx resistant symptomatic supraventricular or ventricular arrhythmias _____ Hx of cardiac arrest or resuscitation _____ Hx of unexplained syncope _____ Brain embolism of cardiac origin _____ Concomitant HIV disease

_

(Severe)





Information obtained from CMS. This sheet is designed as a tool to help determine prognosis as it relates to making a hospice referral. This sheet is not intended to be used to formulate diagnosis and does not confirm/rule out hospice qualification. If the patient meets the factors below you may wish to make a referral to Hospice of Spokane. You may do so by calling 509.456.0438 or filling out the online referral form at http://hospiceofspokane.org/admissions.html.







Qualifying Hospice Guidelines for HIV

_____ CD4+ <25 cells/mcl ORLab Tests:

Terminal stage will be considered if at least lab test plus one HIV co-morbidity and a Karnofsky Performance Status (KPS) of less than or equal to 50% (See back for Karnofsky Status).

_____ Persistent viral load >100,000 copies/ml (2 or more assays at least one month apart)

HIV co-morbidities: _____ CNS lymphoma

_____ Untreated (or persistent despite tx) wasting (loss of at least 10% lean body mass)

_____ Mycobacterium avium complex (MAC) bacteremia untreated/unresponsive to tx

_____ Progressive multifocal leukoencephalopathy

_____ Systemic lymphoma w/ advanced HIV disease & partial response to chemotherapy

_____ Visceral Kaposi’s sarcoma unresponsive to therapy _____ Renal failure in the absence of dialysis

_____ Cryptosporidium infection _____ Toxoplasmosis unresponsive to therapy

Supporting factors for hospice eligibility

Chronic persistent diarrhea for 1 year _____ Absence of or resistance to effective _____ antiretroviral, chemotherapeutic and prophylactic drug therapy related to HIV dx Persistent serum albumin <2.5 _____ Advanced AIDS dementia complex _____ Concomitant, active substance abuse _____ Toxoplasmosis _____ Age >50 years _____ CHF, symptomatic at rest _____ Advanced liver disease _____



Moribund / imminent death 10 _____Very sick / active supportive tx 20 _____Severely disables / req close monitoring 30 _____Disabled / req special care /assistance 40 _____Req much assistance / freq med care 50 _____Req occasional assist / self care most ADL 60 _____Self Care ADL’s / limited activity 70 _____Normal activity with effort / S&S of dx 80 _____Normal activity / minor S&S of dx 90 _____No evidence of dx 100 ____









General Hospice Guidelines for Liver Disease

_____ Prothombin time >5 secs over control or INR >1.51. Lab tests should have both values:

Liver disease: Data from both 1 & 2 should be present to qualify for hospice care.

_____ Serum Albumin <2.5 gm/dl

2. Should have at least one of the following co-morbidities: _____ Ascites refractory to tx or patient non-compliant

_____ Spontaneous bacterial peritonitis

_____ Hepatorenal syndrome w/ elevated creatinine and BUN w/ oliguria (<400 ml/day) and urine sodium concentration <10 mEq/l _____ Hepatic encephalopathy / refractory to tx or patient non-compliant

_____ Recurrent variceal bleeding despite intensive therapy

Supporting Data (if available) _____ Progressive malnutrition _____ Muscle wasting w/ reduced strength & endurance _____ Cont. active alcoholism (>80gm/day) _____ Hepatocellular carcinoma

_____ HBsAG positive (Hepatitis B) _____ Hep C refractory to interferon therapy

Other Co-morbidities: Pick one or more values

Liver disease _____ Neoplasia _____ AIDS _____

COPD _____ CHF _____ Ischemic heart disease _____

Diabetes mellitus _____ Neurologic dx _____ Renal failure _____

Dementia _____ Other _____



Qualifying Hospice Guidelines for Pulmonary Disease

End-stage pulmonary diseases should have both 1 and 2 to qualify for hospice care; 3, 4, and 5 support diagnosis and prognosis of 6 months or less.

______ Hypercapnia as evidenced by pCO2 >50mmHg within 3 months

1. _____ Disabling dyspnea at rest / poorly or unresponsive to bronchodilators resulting in decreased functional capacity (bed to chair existence/fatigue/cough),(FEV1 <30% of predicted - not necessary to obtain)

AND ______ Progression of end stage pulmonary disease as evidenced by increasing visits to ER or hospitalization for pulmonary infections and/or respiratory failure or increasing MD home visits (decrease in FEV1 >40ml/yr is evidence of disease progression – not necessary to obtain)

2. ______ Hypoxemia at rest on room air as evidenced by pO2 <55mmHg OR

______ Oxygen saturation <88% on supplemental O2 OR

3. ______ Right Heart Failure (RHF) secondary to pulmonary disease (cor pulmonale)4. ______ Unintentional progressive weight loss >10% of body weight over past 6 months

5. ______ Resting tachycardia >100/minNon-disease specifi c guidelines to be used in conjunction with above criteria (both A and B should be met)A. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) <70% (See back) KPS _________ PPS _________

B. Must be dependent in 2 or more of the following ADLs

Transfer _____ Bathing _____ Dressing _____Other _____

Co-morbid conditions:

COPD _____ CHF _____ Ischemic heart disease _____ Diabetes mellitus _____ Neurologic dx _____ Renal failure _____Liver disease _____ Neoplasia _____ AIDS _____



Qualifying Hospice Guidelines for Renal Disease

_____ Uremic pericarditis

Acute Renal Failure:1 and either 2 or 3 or 4 should be present to qualify for hospice care

1. Dialysis:

_____ Patient seeking neither dialysis nor renal transplantation OR

_____ Discontinuing dialysis

2. Creatinine clearance: _____ <10 ml/min (<15 ml/min for diabetics) OR

_____ <15 ml/min (<20 ml/min for diabetics) with co-morbidity of CHF

3. _____ Serum creatinine >8 mg/dl (>6 mg/dl for diabetics)

4. _____ Estimated GFR <10 ml/min

Acute Renal Failure – Co-morbid conditions

_____ Mechanical ventilation _____ Malignancy of other organ system

_____ Chronic lung disease _____ Advanced cardiac disease_____ Advanced liver disease _____ Albumin <3.5 gm/dl

_____ Immunosuppression / AIDS _____ Platelet count <25,000_____ Disseminated intravascular coagulation _____ GI bleeding

Chronic Kidney Disease:1 and either 2 or 3 or 4 (see above) should be present to qualify for hospice care

Supporting Signs and Symptoms of Renal Failure: _____ Uremia _____ Oliguria (<400 ml/24 hrs)

_____ Hyperkalemia (>7.0) not responsive to treatment

_____ Hepatorenal syndrome _____ Intractable fluid overload not responsive to treatment






Karnofsky Status – Pick one value (status 70% or less required)






Qualifying Hospice Guidelines for Stroke/Coma

_____ Dysphagia severe enough to prevent patient form continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition and hydrationComa (any etiology):1. Comatose patients with any 3 of the following on day three of coma:

Stroke:

_____ Weight loss >10% in past 6 months or >7.5% in past 3 months

_____ Serum albumin <2.5 gm/dl;

_____ Abnormal brain response _____ Absent verbal response _____ Absent withdrawal response to pain _____ Serum creatinine >1.5 mg/dl

1. Decline in Karnofsky Performance Status or Palliative Performance Score of <40%. (See back) KPS _____ PPS_____AND

2. Inability to maintain hydration and caloric intake with one or more of the following:

2 and 3 are factors which support poor prognosis and hospice eligibility

_____ Refractory stage 3-4 decubitus ulcers _____ Fever recurrent after antibiotics

_____ Obstructive hydrocephalus in pt who declines or not a candidate for ventriculoperitoneal shunt

3. Diagnostic imaging support poor prognosis after stroke include: a. Non-traumatic hemorrhagic stroke

2. Documentation of medical complications, in the context of progressive clinical decline, within the past 12 months, would support a terminal prognosis. _____ Aspiration pneumonia _____ Pyelonephritis

_____ Supratentorial ≥50ml _____ Infratentorial ≥20ml

_____ Large-volume hemorrhage on CT _____ Surface area involvement of hemorrhage >30% of cerebrum

b. Thrombotic/embolic stroke:

_____ Large anterior infarcts with both cortical & subcortical involvement_____ Basilar artery occlusion

_____ Large bihemispheric infarcts

_____ Bilateral vertebral artery occlusion

_____ current history of pulmonary aspiration not responsive to speech language pathology intervention; sequential calorie counts documenting inadequate caloric / fluid intake

_____ Midline shift >1.5cm _____ Ventricular extension of hemorrhage








Karnofsky Score (<70%) _____


Qualifying Hospice Guidelines · Support and Care for Terminally Ill Patients and their Families...

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